Consultant: Clinical Auditor - Centurion
PPS Recruitment
Job Advert Summary An exciting opportunity for an analytical and attention-to-detail Clinical Auditor exists in the Hospital Benefit Management group. The successful candidate will utilise their Clinical Audit experience to audit hospital accounts in order to identify irregular billing by both the hospitals and providers. Furthermore, identify clinical risks and trends that might influence costs to the Scheme. Applications are invited for the above-mentioned position, to be filled as soon as possible. Minimum Requirements Nursing qualification. Clinical Auditing experience Minimum of 2 years' experience in the managed care environment Duties and Responsibilities Conduct clinical audits on claims and costs to ensure correct payment of claims to providers and members Accumulate/Investigate data using clinical experience to highlight risks and trends which might influence the costs to the scheme Compile audit reports to point out trends and risks Liaise with providers to develop and maintain relationships Assist in the settlement of claims disputes to ensure correct payment of claims Research new medical and surgical instrumentation and products to keep the company abreast of changes in the industry Provide Clinical input into work directives and protocols to assist PMSA with clinical decisions Participate in negotiations with service providers in order to assist the Scheme with the cost effective management of resources Required to assist with the review of policies, protocols and formularies from a clinical and financial position Evaluate current medicine usage trends and compare with those of local and international sources for best practice Monitor medical literature and use evidence-based principles to generate enhancements in funding protocols Review and research new drug trial results, in collaboration with the Medical Advisor Answer clinical queries from Providers within the Schemes' SLA requirements Perform tasks timeously and with necessary detail in response to issues raised Provide input and support to the Clinical Committees, MHC meeting and other committees as and when required Assisting with all adhoc requests on any clinical matters when required Maintain information gathered on knowledge management portals Proactively identify and manage potential problems/escalations within customer base with appropriate resolution plans
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